Dr Helen McIver debates the effectiveness of one-day training for injectables
Aesthetic medicine receives criticism for its lack of regulations and places great emphasis on the importance of procedures being carried out solely by medical practitioners. However, outside the fact that any lay person can be trained, medical practitioners are allowed to perform aesthetic treatments after only a one-day training course. Following my own experience on these courses, I personally do not believe they provide adequate training to allow practitioners to venture into the complex and potentially high-risk world of injectable fillers. This article aims to explain why, as well as what I believe practitioners should seek to do instead.
A typical one-day course commonly provides a morning of theory and observation of one patient and an afternoon of supervision, usually with each student treating one, or even just practising on a dummy. The student is usually then certified to carry out such a treatment, providing they gain appropriate insurance. In other fields of medicine, such as dentistry, short postgraduate courses exist to increase a practitioner’s skillset, as opposed to gaining the initial qualification to begin practising in the subject.
A one day orthodontic course, for example, is frowned upon in the field of dentistry as it is not thought that a dentist can gain the full knowledge and skillset required in one day and without any form of examination of the dentist’s understanding and competency. Specific aesthetic procedures are often not directly covered through formal ‘dermal filler’ training courses and, although guidance has been produced by bodies such as the CPSA and JCCP,1,2 there are no legal definitive training requirements for each procedure. Moreover, there is no such thing as a ‘cosmetic’ specialty for medical professionals, making it difficult for patients to know if their practitioner is appropriately qualified or experienced in that particular field.3
I see aesthetic practitioners asking questions on forums on a daily basis, which I am sure would frighten their patient. “What product should I use to fill X,Y,Z?” and “How deep should I inject for…?” are regular questions I see and I feel this level of misunderstanding by individuals who are qualified to carry out such a procedure is unacceptable. Imagine seeing on a forum, “How should I extract this particular tooth?” – such a practitioner would likely be advised to seek more training and assessment.
The traditional ‘see one do one’ concept has been shown to work in surgical teaching for medical students, but only when combined also with ‘teach one’. There are now arguments that this method is no longer applicable, mainly because of concerns for patient safety.4 I do not believe that it works well in aesthetics due to the complexity of the field, vast amount of new information not covered in any of the practitioners’ undergraduate courses, and great variations between each individual patient. I do not feel that observing and treating one patient under supervision, without the guarantee that the supervisor has even paid full attention, which I have personally experienced on courses, is adequate teaching and mentoring to gain a full qualification. I believe competency must be gained with a number of different and repeated treatments on a large number of patients under mentorship.
From my knowledge, many providers that grant qualifications to practise are offered to medical professionals with the assumption that they have prior knowledge of anatomy and general medicine. Whilst the latter is true, an assessment is not made of how relevant their previous training is to the field of aesthetic medicine. How many doctors, dentists, nurse practitioners, midwives and pharmacists know the in-depth anatomy of the glabellar complex, or could draw the path of the facial nerve and its varying depths prior to, or following, a beginner’s facial aesthetics course? Anatomy, and its variation amongst individuals, is a vast subject. Factor in the different types of treatments available, the treatment planes, the depth of injections, and the rheology of materials, it is clear that aesthetic medicine is a complex subject, requiring extensive knowledge and confidence in dexterity.
I have found that the more you learn, the more you realise you do not know, hence the reason why thorough training and supervision over an extended period of time is paramount, in my opinion.
I do recognise that there can be some positives of one-day courses. Basic training does allow the medical practitioner to begin their career in aesthetics quickly, at a relatively low cost and without having to prepare for exams. It can also give them an insight into the field to determine if they are keen and would like to progress
further, before investing more time and expense. It is also a way for experienced professionals in aesthetics to be able to run courses and share their enviable skills with novice practitioners, or those who are experienced looking to build upon their skills and learn new techniques, without the need to complete a post-graduate qualification in teaching.
Alternatively, we are now gaining access to many online resources which could be used to gain introductory information and allow practitioners to decide if they wanted to pursue the field further by investing in courses. I am therefore of the belief that the negatives of gaining qualification via a one-day course far outweigh the positives.
The solution There are several solutions to this problem, some already in place and some which I believe should be enforced. Many courses providing an advanced postgraduate qualification in aesthetic medicine exist, namely the Master’s of Science, Diploma, Level 7 certificate and Level 7 Diploma. The Royal College of Surgeons (RCS) has produced guidance outlining standards for cosmetic practice (surgical and non-surgical), advising that attendance at training courses alone is insufficient to become competent in a procedure; direct training and supervised practice is also necessary; and a period of formal or informal mentorship is recommended.3
Prior to being able to treat patients without supervision, I believe that success in some form of written and supervised assessment should be compulsory in order to ascertain that the practitioner has understood what they have been taught, as well as being able to demonstrate an adequate level of competency in injectables. I feel that this should include an evaluation of a practitioner’s understanding of complication risk assessment and management. This in turn ensures the safety of patients and an adequate level of quality of the work to be carried out, while also further protecting the practitioner.
This movement is already coming to fruition, with associations such as the BCAM implementing an exam in order to gain membership.5 The CPSA has standards in place to provide solutions to the issues addressed, to ensure practitioners’ competence and patient safety, while the JCCP has specific requirements for joining its register in association with the CPSA.1 They promote practitioners to move away from lone practice and develop networks; recognise competence as appropriate knowledge, skills and behaviours, and believe that competence can only be achieved through appropriate supervision.6
I believe that practitioners’ expertise and confidence would improve by undergoing a mentorship programme at the start of their career in aesthetics. Having someone present in clinic to discuss treatment planning and provide supervision, guidance and constructive criticism would encourage development of critical skills and learning.
I myself enrolled onto the Level 7 Qualification in Injectables with a well-known training provider for this reason. This comprised in-depth studying of many aspects of injectable medicine: from its history, anatomy and material science to the psychology and law associated with it; an OSCE examination, dissertation and several one-to-one observation and supervised training days, treating at least eight patients per day. I found this to be invaluable in my journey; feeling so much more confident and safer with my in-depth knowledge and experience, as well as having a wonderful support system around me, and now wonder how I ever treated patients prior to undertaking this intensive training course.
Aesthetics can be a scary field that can carry a high risk if left in the hands of someone with minimal training. This can lead to two things: one is a lack of confidence which can actually dissuade the practitioner from continuing in the field at all,7 and the other is over-confidence of the practitioner from a lack of knowledge and anatomical danger zones, which can lead to unsafe practice.
I believe that although short group courses provide some positives to practitioners and trainers, the training they provide is insufficient without continuing professional development. Enforced assessment and mentorship would be beneficial to both practitioners and patients in the long run, along with improving the standards of the aesthetic field, helping to bring it in line with other specialties of medicine.
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